Introduction:
The beneficial effects of cardiac rehabilitation (CR) on morbidity and mortality after an acute coronary syndrome (ACS) are well established. Despite guidelines, CR referral rates have been low. Determining factors associated with CR referral would assist in closing this care gap and improve outcomes. Using the Canadian Global Registry of Acute Coronary Events (GRACE) database, we examined 1) the temporal trends of CR referral rates in Canada and its associated factors in a contemporary setting; 2) use of evidence-based medical therapies after ACS and its relationship with CR referral during index hospitalization.
Hypothesis:
CR referral rates have increased over time but remain below current guideline recommendations.
Methods:
From the Canadian GRACE registry, we retrospectively analyzed data from 11 Canadian centers during 2000 - 2007. CR referral rates were established and analyzed over time. We compared the CR Referral group to the Non-CR Referral group using univariate logistic regression in regards to patient characteristics, in-hospital diagnosis, clinical events and investigations. Categorical and continuous variables were compared using the chi-square and the Wilcoxon rank sum tests, respectively, with statistical significance at p<0.05. Data of guideline-recommended medication use at discharge and 6 months post-discharge were also analyzed.
Results:
In the 8-year period, 3338 patients (median age 64 years, 32% women) were assessed. Initial CR referral rate in 2000 was 2.7% (6/219) and increased to 51.2% (220/430) in 2007 (p<0.0001). Univariate factors for CR referral include younger age, larger infarct size, and a diagnosis of STE-ACS. Univariate factors for non-CR referral include CHF, higher GRACE score, and previous CAD. Hospitals with on-site supervised CR facilities had higher CR referral rates. CR Referral group had higher usage of evidence-based medications at time of discharge as well as 6 months post-discharge (all p< 0.0001).
Conclusions:
There has been a steady increase in CR referrals; however, contemporary numbers are still below the current recommendation of an 85% referral rate. Higher usage of recommended medications in the CR Referral group were noted, likely reflecting the association of CR referral with overall quality of care. Factors associated with CR referral include younger age, larger infarct size, and STE-ACS. Lack of referral was associated with CHF, previous CAD and high GRACE score. Targeting non-referred populations may improve quality of care and close care gaps in secondary prevention.
Six-month mortality rates are lower in patients with an acute coronary syndrome treated with the combination of clopidogrel and a statin than in patients treated with either therapy alone: An analysis from the global registry of acute coronary events
